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Toilet Flushing and SARS Connection

People got SARS from toilet flushing
By Judi McLeod Monday, March 17, 2008

On Thursday when Hong Kong shut all kindergartens and primary schools, affecting more than 500,000 children, Toronto environmentalist Maureen Reilly, BA sent an email to Scott Dowell, Coordinating Officer for Global Health, Center for Disease Control (CDC) in Atlanta, Georgia.

Reilly, who is researching the proper protocol for managing fecal waste from Severe Acute Respiratory Syndrome (SARS), has for the past decade studied the issue of pathogens in municipal effluents and land applied sludge wastes.

“I am wondering how SARS (or avian flu) fecal waste should be managed in a hospital setting,” she wrote Dowell.

Citing issues that include the aerosolization of pathogens into the washroom (i.e. Amoy Gardens (Hong Kong); the infection of sewage treatment workers; the release of pathogens into receiving waters in sewage effluents, the application of sludges on farm and food chain lands and the development of more virulent forms of the pathogen through the sewage treatment plant processes, the environmentalist asked “Shouldn’t the fecal waste in these cases be autoclaved?”

One of the most effective methods for the destruction of all types of micro-organisms, the autoclave is a pressurized, steam heat vessel used for sterilization.

“I did some SARS work long ago but didn’t focus on fecal waste,” Dowell wrote back to Reilly. “And why are you interested in SARS at this point?”

“The common toilet,” says Reilly, “is not a disinfection machine.”

“I now have emails from Dr. Donald Low, microbiologist in chief at Toronto’s Mount Sinai Hospital and from the CDC saying that the protocol for SARS-infected feces is the toilet,” Reilly told Canada Free Press (CFP). “But reports prove that flushing toilets aerosolized the pathogen, infecting hundreds.

“Even one SARS hospital reported that the nurses in two infected wings shared a washroom.

“What is going on? Don’t they read their own reports?

“And why is it that in 2003—the year of SARS—Toronto spread only 3% of its sludge on farmland”
“Do you think they decided not to because of SARS, but couldn’t tell anyone because how could they get the SARS across the border to the US landfill they were using?”

The respected environmentalist whose work appears in the Canadian Journal of Infectious Diseases, (see full report here) could have easily written back to the CDC when asked why she was interested in SARS at this point. “No better time to be interested in SARS then now”.

The World Heath Organization banned Toronto as a travel destination in 2003. Forty-four people died from SARS when Toronto resident Sui-Chu Kwan, 78 and her husband returned to Toronto from Hong Kong. The couple had stayed at the Metropole Hotel, which was believed to be the source of the outbreak.

In addition to closing schools, the Chinese government last week named Yuen Kwok-yung, a University of Hong Kong microbiologist who helped discover the cause of the 2003 SARS outbreak, to head a panel charged with finding whether flu strains are mutating into a more lethal form.

Hong Kong remains on flu alert after the unexplained deaths of four young children with flu-like symptoms.
“Worried residents are donning surgical masks, flooding hospital waiting rooms and buying up supplies of antibacterial soap as they remember the SARS outbreak that killed 299 people five years ago.” (Bloomberg.com, March 16, 2008).

There is no proof that the flu-like symptoms that killed four Hong Kong children was SARS. But neither is there any proof that it is not SARS or proof that SARS, which disappeared in 2003, won’t be coming back.

“When SARS first happened, it was sporadic and no one expected it to become a disaster,” said Wong, who also has a 6-year-old daughter. “The recent deaths are haunting me.”

The first in the current spate of deaths was that of a 21-month-old boy on Feb. 24, the city’s Health Department said. Two of the victims tested positive for influenza A, although the disease hasn’t been identified as the cause of their deaths. Two other children died after suffering flu-like symptoms, though tests haven’t yet confirmed the presence of influenza A, the subtype that causes seasonal outbreaks of the disease.

“Hong Kong is simply experiencing a seasonal flu outbreak,” said peter Cordingley, the Manila-based spokesman for the World Health Organization’s Western Pacific region.

“If you look back to SARS, you can understand why there is a high level of anxiety in Hong Kong among the public at the moment,” he said. “There is nothing exceptional n what is happening in Hong Kong at the moment.”

But microbiologists are tying to find whether flu strains are mutating into a more lethal form.
Surely the time to decide the proper protocol for the management of SARS patients’ fecal waste should be determined before another potential outbreak.

“We know that the Corona virus (SARS virus) lives up to 24 hours on surfaces,” says Reilly. “We know the feces are infectious. We know hundreds of people in Amoy Gardens got SARS from aerosols from a flushing toilet.
The same people at risk during the 2003 SARS outbreak are still at risk.

“There are risks to patients and hospital staff from SARS virus aerosolized in the toilet (both inhaled and from later touching surfaces).

“There are risks to sewage treatment plant workers. There are risks to the environment if the virus is released into surface waters, onto farms in sludges, and know that there is a risk of infecting not only people but also animals.

“We also don’t want those virulent diseases sharing that virulent DNA and creating new pathogens in the sewage treatment plant. DNA is shared—increasing virulence and antibiotic resistance factors during the sewage process.

“The infectious fecal waste should be destroyed in all instances—not passed along to workers, and into the environment.

Some of the answers in mitigating the SARS risk to human life lie in the past.

“I was told by an Environmental Health Officer in Durham Region that after the SARS outbreak in 2003, all the SARS patients home addresses were tracked down by health authorities to see if they lived on a septic system, to see if the system had been emptied, and if so, where was the fecal material placed.

“So the Public Health Department WAS worried about the potential of passing on SARS through placement of fecal waste into the environment.”

Meanwhile, we need to think these things through in the event of another SARS outbreak.
“The common toilet,” says Reilly, “is not a disinfection machine.”
Posted 03/17 at 07:38 AM Email (Permalink)

I suggest caution in reading this article.
It is very difficult to follow the data and attributions but the link with flushing toilets seems to be solely the inference from the main source for the article, Toronto environmentalist Maureen Reilly.
JT

Thought has a dual purpose in ethics: to affirm life, and to lead from ethical impulses to a rational course of action - Teaching Reverence for Life -Albert Schweitzer. JT

Comment

In 2003 I went to a presentation by one of the main scientists infolved in the Amoy Gardens outbreak. He presented two possibilities for transmission, and deflated rumours about the broken sewer pipe outside in the street.

One hypothesis was the lack of traps in the 'main stack' pipes that lead to the toilets. Hence there was an updraft from the pipe into the bathroom - that draft was easily shown with airflow tests. If I recall correctly, he also debunked the flushing idea - the updraft is temporarily a downdraft with the flush.

The second hypothesis was rats, moving among the apartments via the balconies, the doors to which were generally open due to the heat and sun exposure. Testing of the carpets and flooring showed high virus counts in the entire apartment, except the bedrooms. Why? - people generally closed the bedroom door at night for privacy, and the rats had free reign over the rest of the apartment.

What has this got to do with the article? Sure, the headline is inflamatory.

Yet, there are serious hypotheses based on the transferance of fecal matter in what we normally think of as "clean" environments.

But when investigators find that a premature "all-clear" decision and a nurse apreciation breakfast were likely the main sources of the second wave outbreak, human error seems a more plausible explanation.

http://www.phac-aspc.gc.ca/publicat/...m3402a-eng.php
"Our analysis of the Ward A nursing staff cohort shows that no nursing staff became ill from exposure to the first cluster of cases on this ward (and, at the time, these patients were not thought to have SARS). This was likely due to the strict adherence to enhanced infection-control practices that were in place. This reinforces what has been found elsewhere that when infection-control measures are in place and adhered to, the likelihood of transmission of SARS is small(9-12). However, when the enhanced infection-control practices were reduced, the exposure to one SARS-affected patient, who required additional care including chest physiotherapy, feeding and all-hygiene care, likely led to transmission to five nursing staff and dramatic amplification of the outbreak. Unaware that they had SARS, several nurses who became ill continued to work after the onset of symptoms, and the virus was spread to other staff members. A further amplification event was likely the nursing appreciation breakfast. "

Comment

I agree with gsgs. It looks like a sensationalistic headline was added and the author (along with Maureen Reilly) may have some axe to grind. The references and interweaving of the current ILI among children in Hong Kong with SARS and aerosolized transmission is a creative journalistic device to bring immediacy to the issue of sewage sludge.

The link to the Reilly article predates the SARS outbreak and is from 2001. It relates to the spreading sewage sludge on farmland in Canada.

The case against land application of sewage sludge pathogens
Maureen Reilly, BA
Maureen Reilly, University of Toronto, Toronto, Ontario.
There is currently a public debate about whether health, agricultural and environmental authorities should continue to allow sewage sludge to be spread on farmland. Some of the concern in the debate is about the pathogen content of sewage sludge. This concern was heightened by the tragedy at Walkerton where Eschericha coli 0157:H7 and other pathogens contaminated the drinking water supply of this Ontario town. The Canadian public were reminded how vulnerable they can be to disease when agricultural practices ajoin population centres without adequate health and environmental controls.
But pathogens are not the only contaminants of concern in sewage sludge. Sewage sludge also contains potentially harmful levels of toxic metals and environmentally persistent chemicals such as polychlorinated biphenyls and dioxins (1).
In the past, farm application was often not the favoured method of disposal. Sludge was incinerated or landfilled, and only a small percentage was applied to farmland. With air quality concerns increasing and landfill capacity at a premium, municipalities have moved to farm disposal of these waste sludges, especially in Ontario, where almost all wastewater sludges are applied on farms.
Have the risks to human health been adequately evaluated? Should government promote the transfer of these wastes to the countryside? Is it reasonable to ask rural residents to live next to sites where human excrement mixed with industrial waste is stockpiled and spread on the land? . . . .

Recent laboratory studies have shown that many SARS patients excrete coronavirus in their stools, where it could survive for longer periods than on ordinary surfaces. As many as 2/3 of the patients in this Amoy Garden SARS outbreak were also having diarrhea, contributing to a significant virus load being discharged in the sewerage in block E. It is probable that the index patient initially infected a relatively small group of residents within block E and subsequently to the rest of the residents in that block through the sewage system, person-to-person contact and the use of shared communal facilities such as lifts and staircases. These residents subsequently transmitted the disease to others both within and outside block E through person-to-person contact and environmental contamination.
The bathroom floor drains with dried-up U-traps provided a pathway through which residents came into contact with small droplets containing viruses from the contaminated sewage. These droplets entered the bathroom floor drain through negative pressure generated by exhaust fans when the bathroom was being used with the door closed. Water vapour generated during a shower and the moist conditions of the bathroom could also have facilitated the formation of water droplets. The chance of exposure was increased given that the bathrooms in apartment units of Amoy Gardens were generally small in size (about 3.5 square metres). Contaminated droplets could then have deposited virus on various surfaces, such as floor mats, towels, toiletries and other bathroom equipment.
Transmission of the disease by airborne, waterborne route and infected dust aerosols has been examined but these were not supported by the epidemiological picture and laboratory results.

Comment

I agree with gsgs. It looks like a sensationalistic headline was added and the author (along with Maureen Reilly) may have some axe to grind. The references and interweaving of the current ILI among children in Hong Kong with SARS and aerosolized transmission is a creative journalistic device to bring immediacy to the issue of sewage sludge.

Yes, that is a good analysis of the article. I don't think we have any debate about it.

Interesting case study of Amoy. Thanks.

There is so much we could learn from the SARS episode, on all sides of the globe. Whether those lessons have been put into public policy, administrative policy and practice is another question.

Comment

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